Hypertensive encephalopathy, eclampsia, and reversibile posterior leukoencephalopathy

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Hypertensive encephalopathy, eclampsia,and
reversibile posterior leukoencephalopathy
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Introduction

• Oppenheimer and Fishberg, 1928
• Hypertensive emergency
• Severe elevation of blood pressure
• that precipitates end organ damage
• Acute pulmonary edema, congestive heart failure,
  ischemic chest pain, retinopathy, papilledema,
  retinal hemorrhagies, aortic dissection, rapid
  deterioration of renal function, hypertensive
  encephalopathy
• Hypertensive urgency
• Severe elevation of blood pressure
• without end organ involvement

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Introduction

• Hypertensive encephalopathy and eclampsia
• are similar syndromes that share a common
  pathophysiology
• Clinical presentation
• Imaging findings
• theraphy

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Cerebral autoregulation

• CBF CPP / CVR CPP MAP - ICP

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Hypertensive encephalopathy-epidemiology

• Rare even in patients with severe elevation of
  blood pressure
• Usually in previously normotensive individuals
• But also in chronically hypertensive patients
• Sympathomimetic drugs (cocaine, amphetamine, MAO
  inhibitors)

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Hypertensive encephalopathy-presentation

• Headache
• Nausea
• Vomiting
• Visual obscuration (blurring to blindness)
• Seizures
• Aleteration in the level of consciousness
• Hyperreflexia
• (Phillips et al., 2002)

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Eclampsia - presentation

• Similar to that of hypertensive encephalopathy
• Association with pregnancy
• 20th week of getation 2nd week after
  parturition
• Lower blood pressures
• Peripheral edema and proteinuria

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Normal perfusion pressure breakthrough

• Patients with severe carotid stenosis who undergo
  carotid endarterectomy and carotid stenting

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Hypertensive encephalopathy-diagnosis I.

• Hypertension as a result of acute stroke vs.
  Neurological symptoms due to hypertension
• Hypertensive encephalopathy is rare
• Hypertensive crisis is rare (1)
• premorbide hystory of hypertension is rare in
  patients who develop hypertensive encephalopathy
• Symptom onset
• Acute and definitive vs. Subacute and progressive
• Symptoms distribution
• Focal vs. Global
• Retinal arteriolar spasms, papilledema, retinal
  hemorrhages

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Hypertensive encephalopathy-diagnosis II.

• Imaging studies
• CT low density changes in posterior regions of
  the brain
• MR more sensitive and specific
• Lesions hyperintense on T2 and hypointense on T1
• Predominantly vertebrobasilar circulation
  (occipital lobes, cerebellum, brain stem),
• but also deep white matter and basal ganglia
• Usually bilateral and symmetrical, white and gray
  matter involvement
• The transient nature of these findings
• reversible posterior leukoencephalopathy (RPLE)

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Hypertensive encephalopathy-diagnosis III.

• Imaging studies
• dwMRI
• Acute diffusion coeficient (increased)
• SPECT (increased flow and increased trcer uptake)
• Lumbar puncture
• Oppening pressure
• Neutrophilic pleocytosis
• TCD (elevated arterial flow velocities)

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Pathophysiology

• Breakthrough of normal cerebral autoregulation
• Extravasation of fluids and proteins
• Vertebrobasilar system more vulnerable due to
  less robust sympathetic innervation
• Reflex vasoconstriction
• Hypoperfusion and ischemia
• Angiografic studies showing vasospasm
• Permanent infarction in some cases

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Theraphy I.

• Reduction of MAP within minutes, but no more than
  20-25 during the first 1-2h, with further
  reduction over the hours to days (Chobanian et
  al., 2003)
• Treatment of end organ damage
• Monitoring (Arterial line)
• Intensive care unit

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Therapy II.

• Antihypertensive agent
• Rapid and predictable onset
• Easy to titrate
• Patients premorbid BP
• Duration of hypertensive emergency
• Concomitant medical disease
• Extent of neurological involvement (rised ICP)

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Therapy III.

• Vasodilators initial titrate
• Sodium nitropruside 0.5-1mcg/kg/min
  as needed
• Nicardipine 5 mg/h at 515min
• Fenoldopam 0.03
  mcg/kg/min 0.05 mcg/kg/min
• Nitroglycerin 5
  mcg/min increments 5 mcg/min
• Enalpril 1.25 mg/6h
• Diazoxide 1-3 mg/kg at 5
  15 min

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Therapy IV.

• Adrenergic inhibitors initial titrate
• Labetalol 20 mg 40-80 mg at
  10 min
• Urapidil 10-50 mg 2-9mg/min
• Phentolamin 5-10 mg 0.2-5mg/min
• Drugo
• Magnesium i.v.

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Therapy V.

• Antiepileptic drugs
• Benzodiazepines
• Phenitoin
• Magnesium

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Prognosis

• Generally complete recovery
• Mortality rate 5

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Primer 1 hipertenzivna encefalopatija
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Primer 2 eklampsija
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Primer 3 normal perfusion pressure breakthrough